Healthcare Provider Details

I. General information

NPI: 1902252125
Provider Name (Legal Business Name): JOSE BALBOA BLANCO SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 06/07/2025
Certification Date: 06/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18761 CHESTNUT CT
MOKENA IL
60448-9501
US

IV. Provider business mailing address

18761 CHESTNUT CT
MOKENA IL
60448-9501
US

V. Phone/Fax

Practice location:
  • Phone: 786-296-5425
  • Fax:
Mailing address:
  • Phone: 786-296-5425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number238.000547
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number15-483
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: